Middle meningeal artery embolization in chronic subdural hematoma: a paradigm shift?

Abstract: Chronic subdural hematoma (cSDH) is a common and growing neurosurgical condition, particularly in the elderly, with high recurrence rates following conventional surgical evacuation. Traditional management strategies primarily address mass effect through drainage but fail to target the underlying pathophysiological mechanisms responsible for hematoma persistence and recurrence. Increasing insights into the role of inflammation, angiogenesis, and fragile neovascular membranes supplied by the middle meningeal artery (MMA) have led to the development of MMA embolization as a targeted therapeutic approach. Over the past decade, MMA embolization has evolved from an experimental salvage technique to an evidence-based intervention. Early observational studies and meta-analyses demonstrated marked reductions in cSDH recurrence and reoperation rates compared with standard surgical management. More recently, large randomized controlled trials have provided consistent, high-level evidence confirming that MMA embolization, particularly as a surgical adjunct, lowers rates of hematoma recurrence, treatment failure, and serious adverse events. Consequently, contemporary consensus guidelines released in 2025 endorse MMA embolization as a class I recommended adjunct therapy for selected patients with nonemergent cSDH. Beyond its adjunctive role, MMA embolization is increasingly being explored as a standalone treatment option. This minimally invasive strategy holds particular promise for frail, elderly patients or those with significant comorbidities who are at high risk for surgical complications. Ongoing trials are aimed at refining patient selection, optimal intervention timing, and embolic techniques. In summary, current evidence supports a paradigm shift in cSDH management toward a pathophysiology-driven, preventive, and increasingly endovascular treatment model. Key Points: Question Does middle meningeal artery (MMA) embolization represent a paradigm shift in chronic subdural hematoma (cSDH) management? Findings Randomized trials show MMA embolization, as a surgical adjunct, reduces recurrence and treatment failure in cSDH, earning a Class I guideline recommendation. Clinical relevance MMA embolization shifts cSDH management from reactive surgical drainage to a proactive strategy targeting the pathologic neomembranes. This pathophysiology-based approach prevents hematoma recurrence, improving long-term outcomes and establishing a new treatment paradigm.